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RENAL > C. RENAL REPLACEMENT > Flashcards

C. RENAL REPLACEMENT Flashcards

1
Q

what is dialysis

A

diffusion of molecules in solution across a semi-permeable membrane along electrochemical conc gradient (high to low)

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2
Q

what % of CKD patients progress to end-stage renal failure and hence need RRT

A

2%

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3
Q

what is dialysis used for

A
  • correct fluid and electrolyte imbalances
  • remove nitrogenous waste products
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4
Q

what are the 4 types of dialysis

A
  1. haemodialysis (HD)
  2. haemodiafiltration (HDF)
  3. peritoneal dialysis (PD)
  4. continuous haemofiltration methods (CHF) - expensive
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5
Q

why is dialysis NOT a cure for kidney failure

A
  • doesn’t correct endocrine functions of kidney: can’t manage vitamin D levels, calcium absorption, EPO stimulation etc
  • eGFR will still be <15ml/min/1.73m2
  • can still progress and may need a transplant
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6
Q

what is haemofiltration

A
  • based mainly on convection, pumped through a system incorporating a semi-permeable membrane
  • the pressure on the blood side pushes plasma across the filter (ultrafiltration)
  • molecules that are small enough <50,000 daltons are pulled across with water in convection
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7
Q

what is haemodiafiltration

A
  • combines convention and diffusion
  • convection is the process during which solutes and solvent move according to the pressure gradient
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8
Q

indications for dialysis

A
  • fluid overload not responding to diuretics
  • uremic convulsions (uric acid in blood (uraemia), into brain)
  • persistent dyspnoea (due to build up of N waste), vomiting, restlessness
  • signs of pericarditis, pericardial effusion
  • profound electrolyte abnormalities
  • eGFR <15ml/min/1.73m (most common reason)
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9
Q

process for a patient with renal failure

A
  • pre-dialysis clinic
  • peritoneal dialysis (less invasive)
  • haemodialysis
  • transplant
  • pre-dialysis clinic for monitoring
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10
Q

pre-dialysis clinic

A
  • aka ‘low clearance clinic’
  • patient assessed for suitable type of RRT with their lifestyle etc
  • aims to slow time until RRT is required
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11
Q

what are the 2 types of peritoneal dialysis

A
  • CAPD (continuous ambulatory peritoneal dialysis)
  • Automated peritoneal dialysis
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12
Q

principles of CAPD

A
  • uses patients body as a filter
  • the peritoneal membrane is semi-permeable
  • the dialysate bag contains neutral fluid to create conc grad
  • dialysate inserted into peritoneal space
  • repeated cycle of instilling dialysate solution into cavity through catheter
  • managed by patient at home
  • doesn’t interfere with life as much
  • dialysate with waste drained into drainage bag
  • risk of skin infections/cellulitis due to tubing from external to internal
  • 1.5-3L fluid each time for 4x daily (bigger patient needs for fluid)
  • the drainage bag is below the catheter site so it drains via gravity (bag strapped to leg, catheter under clothes)

*synthetic membranes bind larger drugs combined with modified cellulose

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13
Q

principles of automated peritoneal dialysis

A
  • solution changed by machine at night
  • exchanges 8-12L during 8-10 hours (asleep)
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14
Q

principles of hameodialysis

A
  • remove blood for cleaning
  • a sonication device: low frequency sound waves which disturb blood, loosens it up and removes waste products
  • arterial pressure monitor
  • LMW heparin pump to prevent clotting: as blood is passed out, through tubes and then back in, if clots in tubes could lead to stroke
  • through dialyser (artificial kidney)
  • venous pressure monitor to check blood isn’t too high/low a pressure
  • clean blood into patient
  • Involves blood being pumped through a system that incorporates a dialyser
  • In the dialyser blood is separated from a crystalloid solution (dialysate) by a semi-
    permeable membrane
  • Solutes move across the membrane via a concentration gradient from one compartment to another by obeying ‘Fick’s law of diffusion’
  • blood and solution is flowing in opposite directions to maintain conc grad
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15
Q

when is haemodialysis required

A
  • someones kidneys have failed to a point that if we do not intervene they may die
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16
Q

questions to ask patient about dialysis

A
  • where is your dialysis done
  • what days do you get dialysis done – affects when we give drugs as otherwise will be filtered out
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17
Q

where, when, how often is HD done

A
  • 3x a week
  • specialist dialysis clinics (not every hospital)
  • each sessions lasts 2-4 hours
  • patients read, write, sleep, walk, watch TV
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18
Q

factors that affect removal of substances for HD

A
  • SA, type & permeability of dialyser
  • Blood flow rate
  • Dialysate flow rate
  • Duration of dialysis
  • Drug: MW, protein binding
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19
Q

factors that affect removal of substances for PD

A
  • Conc grad between dialysate and plasma
  • Peritoneum permeability (as get older, it decreases)
  • Volume and frequency of changes
  • Drug: Vd, protein binding, renal excretion
20
Q

how are small molecules removed

A

diffusion

21
Q

how are larger molecules removed

A

convection

22
Q

properties of drugs most likely to be dialysed

A
  • low MW (larger will diffuse more slowly)
  • (HD < 500 Da, HDF < 20,000 Da as using convection aswell)
  • low protein binding
  • small Vd (<1L/kg) as lots of drug is concentrated in the circulatory system and not passed into external tissues
  • water soluble (as hydrophilic)
  • renally cleared (>50%)
23
Q

ideal drug for a renal patient

A
  • non-renal excretion
  • no SEs
  • active drug
  • no renally excreted metabolites

*odd to get all these for one drug!

24
Q

complications with HD

A
  • Hypotension
  • Muscle cramps
  • Clot formation (hence use heparin)
    (main 3^)
  • Sepsis
  • Hepatitis
  • Disequilibrium syndrome
25
Q

complications with PD

A
  • Protein loss
  • Exit site infection
  • Peritonitis (change to HD?)
  • Abdominal pain
  • Hernia
  • Lower back pain
  • Pneumonia
26
Q

role of pharmacist in RRT

A
  • Check what type of dialysis the patient has
  • Find out what days the patient has dialysis on, and for how long each
    dialysis session lasts
  • If they have it at a dialysis unit, which dialysis unit are they under and who is the consultant in charge
  • Is the dialysis unit aware that their patient has been admitted (Most hospitals have dialysis but it may be a satellite of another hospital)
27
Q

can 1 kidney achieve normal kidney function

A

yes

28
Q

treatment of choice for ESRD

A
  • renal transplant - improves survival and offers better QoL
  • lowers morbidity and mortality rates
29
Q

the 2 sources of organs

A
  • deceased donors (non-heart-beating)
  • living donors (heart-beating) (related or non-related)
30
Q

what medicines may be required for renal transplant patients

A
  • Immunosuppression, unless an identical twin (usually tacrolimus (Adoport) +/- mycophenolate +/-
    Prednisolone)
  • Prophylaxis medicines
  • Pain relief and laxatives
  • Pharmacist may be required to review pre-surgery medicines
  • May require stress ulcer prophylaxis
  • may need to stop anti-coagulants before surgery
31
Q

donor and recipient matching

A
  1. blood group matching
  2. tissue type matching
  3. cross matching

*applies to living and deceased kidney donation

32
Q

blood group matching

A
  • Type O most common (type O can donate to type O, A, B, AB)
  • then A (type A can donate to type A, AB)
  • then B (type B can donate to type B, AB)
  • then AB (type AB can donate to type AB)
33
Q

tissue type matching

A
  • Known as HLA testing (Human Leukocyte Antigen)
  • Out of >100 antigens, 6 are important in transplantation
  • Inherit 3 from each parent
  • Except in identical siblings, chance of a 6 antigen match is 1 in 100,000 (normally 2/3 match with donor)
  • In some cases transplants with no matching antigens are not rejected
  • No way to predict who will experience rejection
  • 6 antigen matches allow for decreased immunosuppressive use
34
Q

cross matching

A
  • Very important part of the work up
  • Repeated just before surgery
  • Blood from donor and recipient is mixed
  • Looking for recipient cells to attack donors
  • Means recipient has antibodies against the donor
  • Cannot go ahead if this occurs
35
Q

how does rejection occur

A
  • patient’s white blood cells reduce or stop the function of the transplanted kidney
  • same way as it fights bacteria / an infection
36
Q

symptoms of rejection

A
  • Fever
  • Decreased urine output
  • Fluid retention
  • Increase in weight
  • Tenderness over the kidney
  • Elevated blood pressure

*most rejection episodes can be reversed with drug treatment but may need to take kidney out

37
Q

hyper acute rejection

A
  • occurs minutes or hours after the transplant
  • this type is very rare, untreatable and the kidney is removed immediately
38
Q

acute rejection (most common)

A
  • can happen at any time after a transplant
  • serum creatinine rises (as using old kidneys)
  • can usually be treated with a higher dose or different type of immunosuppressive medicine until the creatinine returns to baseline
39
Q

chronic rejection

A
  • may develop after months or years
  • there is no known treatment as already on immunosuppressives so they mustn’t be working
40
Q

3 classifications of immunosuppressive regimens

A
  1. induction
  2. maintenance
  3. antirejection
41
Q

induction regimens

A
  • usually higher doses
  • provide intense early postoperative immune suppression
  • use monoclonal or polyclonal ABs
42
Q

maintenance regimens

A
  • used throughout the patient’s life to prevent both
    acute and chronic rejection (bigger role for specialist pharmacist prescribers)
43
Q

types of maintenance immunosuppressive drugs

A
  1. Antiproliferative Immunosuppressants
    - Azathioprine
    - Mycophenolate Mofetil / Mycophenolic Acid (Myfortic) MOST COMMON
  2. Calcineurin Inhibitors
    - Ciclosporin (BRAND specific if using oral form) NEXT MOST COMMON
    - Tacrolimus (BRAND specific if using oral form!)
    this is due to different release kinetics
  3. mTOR Inhibitors
    - Sirolimus (BRAND specific if using oral form!)
  4. Corticosteroids
    - Prednisolone: usually life-long and may be doubled in acute situations
44
Q

why are transplant patients usually very compliant

A
  • patients realise rarity of a transplant and must look after it
  • do not want to jeopardise – unlikely to get a second transplant
45
Q

other support drugs for renal transplant

A
  1. Antibiotic prophylaxis
    - Co-trimoxazole (for PCP) – normally taken for 12 months after transplant
  2. Antifungal prophylaxis
    - Nystatin (gels etc) – normally taken for 3 months after transplant
  3. Antiviral prophylaxis
    - Valganciclovir – normally taken for 100 days after transplant
  4. Tuberculosis prophylaxis
    - Isoniazid and Pyridoxine – usually for first 12 months after transplant if indicated (ie at risk)

RENAL (13 decks)

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